To evaluate the hematological markers in patients having nutritional anemia attending National Institute of Medical Sciences Hospital of Jaipur, Rajasthan

Abstract

Background: 

Nutritional anemia is the most common preventable cause of anemia. Anemia of nutritional origin is an acquired problem caused by consumption of diets that lack sufficient quantity of vitamin B12 levels and serum iron and other components. As per World Health Organization guidelines, hemoglobin (Hb) of <10 g/dL concentration treated as anemia. Nutritional anemia is identified by determining Hb concentrations, evaluating red cell indices and examining peripheral blood picture accompanying serum iron parameters and serum vitamin B12 level.

Objectives: 

To study complete blood count indices with different serum vitamin B12 levels and serum iron profile among nutritional anemia patients attending NIMS Hospital, Jaipur.

Materials and Methods: 

An observation study was conducted among 274 patients having nutritional anemia from General medicine out patients between 15 and 60 years. Two blood samples were collected from each participant to estimate the complete blood counts and red blood cells (RBCs) morphology and to analyze the iron profile and vitamin B12.

Results: 

This presence study shows nutritional anemia in 55% of women than men. 15.6% of patients were from age group 15–20 years. 56.57% patients had moderate anemia, 29.92% patients had severe anemia, and 13.56% patients had mild anemia. Study shows 55% population were nonvegetarians and 45% had vegetarian diet. Microcytic hypochromic blood picture was found in 59.49% patients.

Conclusions: 

Nutritional deficiency anemia was the most prevalent anemia. Peripheral smear is in concordance with serum iron parameters and serum vitamin B12 level. Our study suggests RBC morphology along with red cell indices in diagnosis and management of nutritional anemia which can be cured by dietary adjustment and fortification of food with iron and other micronutrients.

Introduction

Anemia is defined by World Health Organization (WHO) as “a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs, which vary by age, sex, altitude, smoking, and pregnancy status.”^[1]

Although anemia may result from a number of causes, there are three primary causes: (1) reduced production of red blood cells, which may result from deficiency in nutrients or hormones, or from disease or other conditions, (2) excessive destruction of red blood cells, often a hereditary problem, and (3) excessive blood loss.^[2] As per WHO guidelines Nutritional Anemia is a syndrome characterize by reduction in the oxygen transporting capacity of blood that can result from excessive bleeding, increased red cell destruction, decreased red cell production or hemoglobin (Hb) content of blood is lower as a result of a deficiency of one or more essential nutrients, regardless of the cause of such deficiency.^[3] Anemia is the most common morbidity, and it affects health, education, economy, and productivity of entire nation. Worldwide, at any given moment, more individuals have iron deficiency anemia than any other health problem.^[4] Anemia burden is high, affecting 27% of the world’s population, for example, 1.93 billion people in 2013. Developing countries account for more than 89% of the burden.^[5] As per WHO (2019), 60.2% children under 5 years are anemic (95% CI: 56.6%- 63.7%),and the average hemoglobin content was 10.5 g/dL ± 1.5 g/dL. Severe anemia was found in 1.8% (95% CI: 1.0-3.2) of children and the mildest form was found in 25.8% (95% CI: 22.4-29.4).. The prevalence of anemia is over half billion among women aged 15–49 years, 29.6% (95% UI 26.6%, 32.5%) in nonpregnant women aged 15–49 years, and 36.5% (95% UI 34.0%, 39.1%) in pregnant women aged 15–49 years.^[6] In 2004, Global Burden of Disease (GBD) update had similar findings. That report estimated that the global anemia prevalence in 2010 was 32.9%, resulting in 68.4 million years lived with disability (YLD). In 2000, GBD report estimated that anemia accounted for 2% of all YLD and 1% of disability-adjusted life years.^[7]

35.3% was the prevalence of iron deficiency anemia. The questionnaire analysis of dietary habit and clinical characteristics revealed that the family history of hereditary disease and the physical activity have an effect on the development of iron deficiency anemia. The statistical analysis showed that having regular breakfast reduced the development of iron deficiency anemia as compared to having irregular breakfast^.[8] As per WHO (2013),the most prevalent anemia among industrialized countries is nutritional deficiency anemia. In poorer area, anemia is worsened by infectious diseases such as hookworm intestine, tuberculosis, malaria, and Human immunodeficiency virus/acquired immunodeficiency syndrome. In developing countries, about 50% of pregnant women and 40% of preschool children. 20% of maternal deaths can be contributed to anemia.^[9] 24% of the men suffer from anemia, and blood Hb concentration is lower than normal level. In India, anemia estimated about 20%–40% of maternal deaths. Anemia is high in ever-married women from 52% in National family health survey-2 (NFHS-2) and 56% in NFHS-3. According to the National Family Health Survey NFHS-3 Anemia in pregnant women has increased from 50% to 59%,while 79% of children aged between 6–59 months are severely anemic.^[10] According to NFHS-5 (2019–2021), 46.3% of pregnant woman aged 15–49 years, 54.4% of woman aged 15–49 years, 71.5% of children aged 5–59 months, and 23.3% of men aged 15–49 years are anemic in Rajasthan.^[11]

National Nutrition Monitoring Bureau (NNMB) and National Family Health Survey (NFHS-3) conducted surveys recently and showed high prevalence of anemia. The statistical records of NFHS-3 showed the prevalence of anemia in 56.2% in woman aged 15–49 years, 57.9% in pregnant woman aged 15–49 years, 79.2% among children aged 6–59 months, and 24.3% in men aged 15–49 years. Prevalence of anemia neither shows time trend nor an appreciable decrease as shown by the data of NNMB, NFHS-2, and NFHS-3. Prevalence of anemia is reported same in urban and rural areas, if gender differences criteria considered the female are at higher prevalence.^[12]

The study shows the maximum number of patients are from the age groups 21–30 years. Out of which, the prevalence of anemia is more in women than men in 15–30 years age group. The 57% study population show moderate anemia, whereas 41% patients show severe anemia. Weakness is the most common presenting symptom in anemic patients followed by fatigue ability while the most common presenting sign is pallor occurs in 98% patients. The most common laboratory findings (59%) are microcytic and hypochromic type peripheral smear. The most common type of anemia is nutritional anemia (84%).^[13]

Subjects and Methods

Study design

It is an observational type of study.

Study area

This study was conducted at the Department of Pathology in association with the Department of General Medicine in NIMS Hospital, and sample was analyzed at central laboratory of Pathology and Biochemistry in NIMS Hospital, Jaipur, Rajasthan.

Study population

The data were collected from the Outpatient Department (OPD) and the Department of General Medicine at NIMS Hospital, Jaipur, Rajasthan.

Study duration

July 2021–May 2022.

Sample size

The study was conducted upon 274 nutritional anemic patients.

Selection criteria of patients

A total of 274 patients who attended the OPD of General Medicine at National Institute of Medical science and Research Hospital were included in the study.

Inclusion criteria

• – Patients of age 15 years and more
• – Hb level < 10 g/dL in all age and sex group

Exclusion criteria

All the patients aged below 15 years with

• – H/o bleeding
• – Major illness such as malignancies, gastric ulcer, and tuberculosis
• – Cases of hemoglobinopathies such as sickle cell anemia and thalassemia
• – Blood transfusion within last 6 months

Statistical analysis

After collecting data, data will be presented by graphical and tabular representation. Descriptive statistics such as means and standard deviation will be calculated for quantitative data or variables qualitative data will be presented in proportion or percentage from. Chi-square test will be used to check the association between qualitative variables. The data were analyzed with SPSS 21.0. Numerical variables are presented as the mean ± standard deviation (SD). Enumeration data and ranked data are presented as percentages. P<0.05 was considered statistically significant. All statistical analysis were performed in SPSS IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.

Sample collection

5 mL venous blood was taken from the patients. 3 mL of blood was taken in plain vial for iron profile and 2 mL of blood will be taken in Ethylenediaminetetraacetic acid vial for hematological investigations. Serum will be separated by centrifugation and used for following biochemical analysis and whole blood is used for hematological analysis.

Sample collection

• A. Swab with 72% ethanol or spirit was used for cleaning and the area was allowed to dry to prevent blood sample from possible hemolysis.
• B. The arm of patient’s is gripped tightly and by another hand’s thumb used for drawing skin taut.
• C. The vein is penetrated by needle at the positioning at 30–40°.
• D. After the collection of blood tourniquet is also released.
• E. A cotton ball with spirit or 72% ethanol was firmly applied on the venipuncture site as soon as the needle is removed.
• F. After removing the needle, the collected blood is dispensed in the appropriate tubes.

Storage

All the collected samples were kept in 4°C temperature for 15 days.

Complete blood count

The blood samples were analyzed using a hematology analyzer (Erba Elite 580) performing analysis on the whole blood collected in Ethylenediaminetetraacetic acid tubes.

Peripheral blood smear

Peripheral smear was prepared using Leishman’s stain and studied under oil immersion objective of compound light microscope to ascertain the morphology of RBCs.

Iron profile

The serum samples were analyzed using a biochemistry analyzer (fully automated CST-180 machine) performing analysis on the whole blood collected in plane tubes.

Vitamin B12

The serum samples were analyzed using a biochemistry analyzer (fully automated Siemens ADVIA Centaur CP analyzer) performing analysis on the whole blood collected in plane tubes.

Results

Samples of 274 anemic patients were analyzed for hematological profile.

• Out of 274 cases, 150 (55%) were female patients and 124 (45%) were male patients [Table 1].

Table 1:: Showing gender-based distribution of cases

Gender-wise distribution of cases depicted in Figure 1.

Figure 1:: Gender-wise distribution of cases

• The patients were between 15 years and 60 years of age. Maximum number of patients 43 (15.6%) were in the age group of 15–20 years followed by 34 (12.4%) in the age group of 21–25, 26–30, and 46–50 years, 31 (11.3%) in the age group 41–45 years, 29 (10.6%) in the age group of 31–35 years, 24 (8.8%) in the age group 36–40 and 56–60 years, and minimum numbers of patients 21 (7.7%) in the age group 51–55 years [Table 2].

Table 2:: Showing age-wise distribution of cases

Age- and gender-wise distribution of cases depicted in Figure 2.

Figure 2:: Age and Gender group Distribution of cases

• Mild anemia was observed in 37 (13.51%) cases; out of which 15 were men and 22 cases were women. 155 (56.57%) were having moderate anemia cases; out of which 68 were men and 87 cases were women; majority of which were women (87 cases). A total of 82 (29.92%) cases were having severe anemia cases; out of which 41 were men and 41 cases were women [Table 3]. Figure 3 showing gender wise grading of Anemia.
• Maximum number of mild anemic patients were seen in 31–35 years of age group (18.92%) followed by 15–20 years of age group (16.22%). In moderate anemic patients number in 15–20, and 46–50 years of age group (14.19%) followed by 26–30 years (12.26%). The severe form of anaemia was highest in 15–20 years of patient age group (18.29%) followed by (17.08%) in 26–30 years age group [Table 4].

Table 3:: Showing gender-wise grading of anemia

Figure 3:: Gender-based distribution of mild, moderate, and severe anemia

Table 4:: Showing age wise distribution of grading of anemia

Age-wise distribution of cases depicted in Figure 4.

Figure 4:: Age-wise distribution of grading of anemia

• Table 5 is showing that microcytic hypochromic picture was a predominant finding in (59.49%) anemia, second common RBC picture in normocytic hypochromic (17.89%), third commonest RBC picture in normocytic normochromic (13.14%), fourth commonest RBC picture in macrocytic (4.38%), and fifth common RBC picture in dimorphic (5.10%).
• Table 6 shows on the basis of red cell morphology and severity of anemia in microcytic hypochromic anemia that severe cases are 47 (57.32%), moderate are 93 (60%), and mild are 23 (62.17%). Along within normocytic hypochromic anemia, sever cases are 12 (14.64%), moderate are 31 (20%), and mild 6 (16.21%). However, in normocytic normochromic anemia, severe cases are 6 (7.32%), moderate are 22 (14.19%), and mild 8 (21.62%). Along within macrocytic anemia, severe cases are 6 (7.31%), moderate are 6 (3.87%), and mild 0 (0%). And for dimorphic anemia, severe are 11 (13.41%), moderate are 3 (1.94%), and mild 0 (0%). Figure 5 showing distribution of cases on the basis of RBC morphology the same was depicted in Table 5.

Table 5:: Showing distribution of cases on the basis of RBC morphology

Table 6:: Showing peripheral smear red cell morphology and severity of anemia

Figure 5:: Distribution of cases on the basis of RBC morphology

Peripheral smear red cell morphology and severity of cases depicted in Figure 6.

Figure 6:: Peripheral smear red cell morphology and severity of anemia

• Among 274 total patients mild form of anemia was observed in 16% vegetarian and 11% non-vegetarian whereas 54% veg and 60% non-vegetarian had moderate anemia, while severe form of anemia was depicted in both 30% veg and non-vegetarian. This data show that most are having moderate anemia due to dietary habit [Table 7]. Figure 7 showing distribution of Hemoglobin cases according to dietary pattern.

Table 7:: Showing Hb distribution of cases according to dietary pattern

Figure 7:: Hemoglobin distribution of cases according to dietary pattern

1. Among study cases majority trend was toward iron deficiency anemia suggested by low S. iron in 175 (63.87%), normal iron 77 (28.10%), and high iron 22 (8.03%). Total iron binding capacity suggested by low TIBC in 73 (26.64%), normal TIBC in 110 (40.15%), and High TIBC in 91 (33.21%) cases As well as low S. ferritin in 166 (60.59%), normal ferritin in 47 (17.15%), and high ferritin in 61 (22.26%) cases. Presence of S. vitamin B12 in significant number of cases is low 143 (52.19%), normal 101 (36.87%), and high 30 (10.94%) [Table 8].

Table 8:: Showing range and distribution of biochemical parameters in anemic patients

Range and distribution of biochemical parameters of cases depicted in Figure 8.

Figure 8:: Distribution range of biochemical parameters

Discussion

In our present study, we found that female patients with nutritional anemia was 150 and that of male patient was 124. The percentage was 55% and 45% for female and male patients, respectively. The prevalence of female patients was much higher than that of male patients. Our study resembled with the studies conducted by some researchers. So, according to Dhanuka et al.,^[14] the prevalence of female patients was higher than male patients, and 30 female and 18 male patients were detected with nutritional anemia. According to Pandey and Singh,^[15] 18 female patients were nutritional anemia, whereas 11 male patients were under nutritional anemia. Our study also resembled with a study conducted by Rani et al.,^[16] in which it is shown that the prevalence of female patients was higher than that of male patients, that is, 42 (93.3%) and 3 (6.7%) female and male patients, respectively. Cedrick et al.,^[17] found that 25% male patients were nutritional anemia and in case of female patients only 20.7% were under the nutritional anemia.

In present study, the most common affected age group with anemia was 15–20 years (15.6%), second commonly affected age group was 21–25 years (12.4%), 26–30 years (12.4%), and 46–50 years (12.4%), and lowest number of cases was noted in 51–55 years (7.7%) which is in agreement with the studies done previously by Cedrick et al.,^[17] and they found that common age group, which had a high prevalence of nutritional anemia, was aged 15–19 years (21.7%), second common age group prevalence of nutritional anemia was 20–29 years (15.2%), and lowest number of cases was in 40–49 years (5.4%). Also, a study conducted by Ratre et al.,^[13] also opposed with our study and in their study, they found that age group between 21 and 30 years were having more prevalence on nutritional anemia and it was 40%, second age group prevalence was 15–20 years (50%), and lowest cases were in 51–60 years (4%).

In present study, the frequency of moderate anemia cases was 155 higher as compared to mild cases was 37 and severe anemia cases was 82. The percentages were moderate 56.57%, severe 29.92%, and mild 13.51%, respectively. The prevalence of moderate anemia among female patients 87 (58%) was much higher than that of male patients 68 (54.84%), severe anemia among female patients 41 (27.84%) was similar that of male patients 41 (33.07%), and mild anemia among female patients 22 (14.66%) was higher than that of male patients 15 (12.09%). Our study, resembled with the studies conducted by some researchers. So, according to Dhanuka et al.,^[14] the prevalence of mild patients was higher than moderate and severe anemia patients. The mild anemia among female patients 14 (46.67%) was higher than that of male patients 13 (72.22%), moderate anemia among female patients 12 (40%) was higher than that of male patients 3 (16.67%), and severe anemia among female patients 4 (13.33%) was almost same as that of male patients 2 (11.11%). In contrast, the study conducted by Ratre et al.,^[13] found in their study that moderate anemia was higher than severe anemia and mild anemia. The moderate anemia among male patients 62 (31.0%) was higher than that of female patients 52 (26.0%), severe anemia among female patients 41 (20.5%) was same for male patients 41 (20.5%), and mild anemia among male patients 3 (01.5%) was comparable with female patients 1 (00.5%).

In the present study, more number 150 (55%) of cases were nonvegetarians as compared to vegetarians 124 (45%). This observation was in contrast to other studies by Kalaiselvam et al.,^[18] as in their study they found that vegetarian 126 (70.8%) was high in number than nonvegetarian 52 (29.2%). But the results of our study opposed by the studies conducted by some authors. So, according to Dhanuka et al.,^[14] found that 48 (100%) nonvegetarian cases in their study.

In the present study, most common picture of RBC morphology observed on peripheral smear examination was microcytic and hypochromic 163 (59.49%) These findings are in concordance with the findings of Kalaiselvam et al.,^[18] and Ratre et al.,^[13] common morphological pattern observed was normocytic hypochromic 49 (17.89%), and normocytic normochromic 36 (13.14%). Similar pattern was observed in the study by Rani et al.,^[16] in their study found that normocytic normochromic 28 (62.2%). Ratre et al.,^[13] study reported normocytic normochromic 12 (6%) but reported dimorphic 52 (26%) picture as the second most common RBC morphology pattern. Third common morphological pattern observed was dimorphic 14 (5.10%) This was on par with the findings of study done by Kalaiselvam et al.,^[18] with results of dimorphic 2 (1.2%). Rani et al.,^[16] morphology pattern observed was dimorphic 1 (2.2%). The least common pattern that was observed in present study was macrocytic anaemia 12 (4.38%), these finding are in concordance with the findings of Ratre et al.^[13]

Conclusion

The present study was conducted in the Department of Paramedical and Technology, NIMS University, Jaipur, Rajasthan between December 2021 and May 2022. A total of 274 positive samples were collected from OPD or the Department of General Medicine at NIMS Medical College and Hospital, Jaipur for the prevalence of Nutritional Anemia in female and male patients. Our study found that:

• The prevalence of nutritional anemia in female patients was high than female patients. 150 patients were women and only 124 patients were men.
• The percentage of prevalence in female patients was 55% and 45% was for male patients.
• The prevalence of nutritional anemia was found high for 15–20 years age group patients both in female and male patients. A total of 25 patients were women and 18 were male patients between 15 and 20 years age group.
• Out of 274 patients, 37 (13.51%) patients were having mild anemia, 155 (56.57%) patients were having moderate anemia, and 82 (29.92%) patients were having severe anemia.
• Among 274 patients 55% (150) patients were non vegetarians whereas 45% (124) were vegetarians.
• Frequency of moderate anemia was little higher in patients taking nonvegetarian diet, where as the frequency of mild anemia was more in vegetarian as compared to nonvegetarian, and severe anemia was similar in patients taking vegetarian as compared to nonvegetarian as per the current study.
• On peripheral smear examination microcytic hypochromic picture was most common followed by normocytic hypochromic, normocytic normochromic, and dimorphic.
• Peripheral blood smear finding showed a significant statistical association with serum iron parameters and serum vitamin B12 level. This suggests the importance of examination of RBC morphology in the diagnosis and management of nutritional anemia.
• Dietary pattern (vegetarian/nonvegetarian) showed a significant statistical association with serum iron markers and serum vitamin B12 level, which suggests a definitive role of diet in the occurrence of nutritional anemia.

Acknowledgments

We are grateful to the subjects, who participated in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.